Nutritional Questionnaire Form

Personal Information

Name

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Email

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Date of Birth

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Gender

Male

Female

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Height (cm)

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Weight (kg)

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Dietary Habits

How often do you eat meals per day?

1-2 times

3 times

4 or more times

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What type of diet do you follow?

Vegetarian

Vegan

Pescatarian

Omnivore

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How many servings of fruits and vegetables do you consume daily?

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How often do you consume the following foods?

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Nutritional Goals and Preferences

Do you take any dietary supplements?

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What dietary supplements?

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Lifestyle Information

How often do you exercise?

Daily

3-5 times a week

1-2 times a week

Rarely/Never

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Additional Comments or Questions

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Description of Each Section

1. Personal Information: Collects basic demographic and physical information.
2. Dietary Habits: Assesses the respondent's meal frequency, dietary choices, and food consumption patterns.
3. Nutritional Goals and Preferences: Gathers information on dietary objectives, allergies, and supplement use.
4. Lifestyle Information: Examines exercise habits and stress levels, which are important for nutritional assessments.

	Daily	3-5 times a week	1-2 times a week	Rarely/Never
Dairy Products:
Meat (including poultry and red meat):
Fish:
Processed Foods (e.g., snacks, fast food):
Sugary Drinks (e.g., soda, energy drinks):

Personal Information

Dietary Habits

Nutritional Goals and Preferences

Lifestyle Information

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